MEDICARE: GEORGE S TELLAM DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	PO 1636	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1750319026	OTHER	FL	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1669843751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGE S TELLAM DPM

Provider Business Mailing Address
First Line	:	981 KINGSLEY AVE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-4742
Country	:	US
Telephone Number	:	904-269-9595
Fax Number	:	904-264-5211

Provider Business Practice Location Address
First Line	:	2710 3RD ST S
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6028
Country	:	US
Telephone Number	:	904-269-9595
Fax Number	:	904-264-5211

Authorized Official
Title or Position	:	OWNER/PODIATRIST
Name	:	SHELLEY SAWDAY THOMAS
Credential	:	DPM
Telephone Number	:	904-269-9595

Provider Enumeration Date	:	10/14/2015
Last Update Date	:	07/29/2020

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Directions to “GEORGE S TELLAM DPM ” Practice Location

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